How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center

Mansouri, Mohammad; Aran, Shima; Shaqdan, Khalid W.; Abujudeh, Hani H.

doi:10.1007/s00330-015-4061-0

Cited by 10 publications

(7 citation statements)

References 50 publications

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“…This includes diagnostic test orders when the wrong patient is tested, medical and technical errors, and incorrect test errors. 23 Similarly, in our study, the most often mentioned mistakes: incorrect procedures, wrong patients, human errors, errors of knowledge, and equipment malfunctions, all occurred during CT scans. It is impossible to estimate from the incident reports how many of the mistakes were a result of knowledge or skill gaps.…”

Section: Root Cases Of Adverse Eventssupporting

confidence: 74%

“…22 A child or human foetus is more sensitive to the effects of radiation, so in these groups, avoiding unnecessary radiation is of utmost importance. 17,19,23 In the current study, pregnancy was not verified in two reports and in two cases, the patient denied pregnancy. A pregnant staff member had been exposed to unnecessary radiation in two cases in radiography and in a CT room when the radiation was accidentally switched on.…”

Section: Annual Reports and Radiation Dosescontrasting

confidence: 61%

“…Previous studies have reported similar findings. 23,24 The root causes of the incidents included incorrect patient identification, equipment problems, human errors, and errors of knowledge. A referral written incorrectly or for the wrong patient was also found to be the root case of unnecessary radiation.…”

Section: Root Cases Of Adverse Eventsmentioning

confidence: 99%

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Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

et al. 2020

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Adverse events in radiology are quite rare, but they do occur. Radiation safety regulations and the law obligate organizations to report certain adverse events, harm and near misses, especially events related to patients' health and safety. The aim of this study was to describe and analyse incidents related to radiation safety issues reported in Finland. MethodsThe data were collected from incident reports documented by radiology personnel concerning notifications of abnormal events in medical imaging made to the Radiation and Nuclear Safety Authority between 2010 and 2017. During these eight years, 312 reports were submitted. Only events reported from radiology departments were included; nuclear medicine, radiotherapy and animal radiology cases were excluded. The final number of reports was 293 (94%). ResultsThe majority of the 293 approved reports were related to computed tomography (CT, 68.3%) and to X-ray examinations (27.6%). Altogether 82.9% of those irradiated were adults, most of whom were exposed to unnecessary radiation through CT (86.5%), 5.5% were children, and 4.4% pregnant women. The most common effective dose of unnecessary radiation was 1 mSv or less (89.7% of all examinations). The highest effective doses were reported in CT (from under 1 mSv-20 mSv and above). The reasons for the adverse events were incorrect identification (32%), incorrect procedure, site or side (30%); and human errors or errors of knowledge Data selection (20%). ConclusionAdverse events occurred especially in CT examinations. It is important to collect and analyse incident data, assess the harmful events, learn from them and aim to reduce adverse events.

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Section: Root Cases Of Adverse Eventssupporting

confidence: 74%

Section: Annual Reports and Radiation Dosescontrasting

confidence: 61%

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Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

et al. 2020

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“…Although these frequencies are somewhat reassuring, it is of particular importance to learn from the errors made in these cases. Previous studies on patient safety incidents in radiology only reported their findings on a meta-level (13,14) or provided only a few selected case examples to illustrate the types of errors made (16)(17)(18)(19)(20). Lack of, incomplete, or selected reporting of relevant individual patient safety incidents in scientific publications may be due to several factors, including liability concerns, compensation claims, and reputational damage (27).…”

Section: Discussionmentioning

confidence: 99%

“…Although data on a meta-level may be relevant to identify system weaknesses, they do not provide sufficiently specific information about the individual errors that were made. In addition, although other studies on this topic reported some examples of patient safety incidents (13,(16)(17)(18)(19)(20), these case examples suffer from selection bias and were not fully reported in terms of patient harm and how they were handled; in particular, patient safety incidents that actually caused harm (21) and those that are serious in terms of risk of patient harm and reoccurrence should be completely reported to learn from and to minimize the risk of repetition.…”

Section: Introductionmentioning

confidence: 99%

Patient safety incidents in radiology: frequency and distribution of incident types

et al. 2020

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Background Patient safety incidents may be a valuable source of information to learn from and to prevent future errors. Purpose To determine the distribution of patient safety incident types in radiology according to the International Classification for Patient Safety (ICPS), and to comprehensively review those incidents that were either harmful or serious in terms of risk of patient harm and reoccurrence. Material and Methods The most recent five-year database (2014–2019) of a radiology incident reporting system was evaluated. Results A total of 480 patient safety incidents were included. Top three ICPS incident types were clinical administration (119/480, 24.8%), resources/organizational management (112/480, 23.3%), and clinical process/procedure (91/480, 19.0%). Harm severities were none in 457 (95.2%) cases, mild in 14 (2.9%), moderate in 4 (0.8%), severe in 3 (0.6%), and unknown in one case. Subsequent Prevention Recovery Information System for Monitoring and Analysis (PRISMA) reviews were performed in 4 (0.8%) cases. The three patient safety incidents that caused severe harm (of which one underwent PRISMA review) involved resources/organizational management (n = 1), clinical process/procedure (n = 1), and medication/IV fluids (n = 1). Three other cases (with no harm in two cases and moderate harm in one case) that underwent PRISMA review involved resources/organizational management (n = 2) and medical device/equipment/property (n = 1). Conclusion Radiology-related patient safety incidents predominantly occur in three ICPS domains (clinical administration, resources/organizational management, and clinical process/procedure). Harmful/serious incidents are relatively rare. The standardly and transparently reported findings from this study may be used for healthcare quality improvement, benchmarking purposes, and as a primer for future studies.

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Computed tomography

MacDonald¹

2019

Oral and Maxillofacial Radiology

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How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center

Abstract: • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

Cited by 10 publications

References 50 publications

Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

Patient safety incidents in radiology: frequency and distribution of incident types

Computed tomography

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